Context.

FDMNs’ condition within the settlements of Ukhia and Teknaf Upazilas (sub-districts) has improved significantly since the arrival of the refugees in 2017. Many temporary shelters in the form of tents have been transformed into housing, separated by pathways three-feet wide and a few roads that are hard to use. Soil erosion is a growing problem, and the risk of deadly landslides triggered by heavy rains is a significant barrier to access health care services.

Security.

Due to the uniqueness of service delivery in an emergency setting, the safety of the service providers is the biggest constraint for the effective implementation of the MNCH programs. Field staff reported that they threatened by the very beneficiaries they were serving. FDMN community members sometimes verbally assault the service providers if they cannot deliver medicine. Moreover, health care providers like doctors and nurses, feel unsafe while working at health posts, particularly without the protection of secure fences, despite the presence of guards at the health facilities.

"Why? This Rohingya community is very violent. If there is any dispute over some issues, they become very dangerous. You really cannot tell what will happen when you are going to work or walking on the road." Res 01_PI_LNGO

Service delivery.

Many organizations offer MNCH services inside the FDMN camps. The overlapping of services is a big challenge and often creates a problem, such as targeting the beneficiaries and the allocation of funds appropriately.

“There have been some areas where services are overlapping, and underutilization of resources is happening in other facilities. Different organizations for the same beneficiaries deliver similar activities." Res 24_PI_INGO

The majority of the centers do not offer 24/7 services, and the laboratory services are very limited. However, in health posts, blood grouping and detection of urine albumin are possible.

Referral.

The referral mechanism in the camp setting is fragile and unstructured. The patients usually are referred to the only referral health facility within the camp, which provides comprehensive emergency obstetric care and the government-run sub-district level health complexes, which provides secondary level health services to the patients. The poor coordination and lack of capacity are the main underlying reasons for the weak referral system. These are exacerbated due to the nonexistent referral guideline, shortage of referral facilities, absence of referral manager, the distance of the referral facilities, and lack of 24/7 transportation facility.

"Yes, it is a big challenge as the referral hospital might be a bit distant. who will bring her to the facility, bear the cost, she also needs one attendant." Res 32_PI_INGO

Sometimes, the health providers at referral facilities avoid receiving complicated patients due to the shortage of specialists or high patient load.

“The lack of capacity of the referral health facility is a problem. Upazila Health Complex is a 50 bedded hospital. Sometimes the patient load is high. Therefore, they provide initial treatment and send the FDMN clients back home.” Res 02_PI_LNGO

Providing MNCH services inside the FDMN camps require unified efforts from the field level staff and the facility level staff. However, due to the presence of untrained traditional birth attendants from the FDMN community and sometimes inexperienced midwives or nurses, handling of emergency cases become complicated. The inexperienced midwives often lack confidence and fail to refer cases on time.

"How would they (TBAs) know? If the case (pregnant mother) was easy, then they may ask the 'Khalash' (to perform the delivery). In case of any problem, the TBA would never know that. It is what we try to make them (pregnant women and their guardians) understand.” Res 20_CO_LNGO

Frequent turnover of staff.

The frequent turnover often hampers the MNCH service provision. Many respondents (6) mentioned that the retention rate of health providers in the health posts inside the FDMN camp, especially doctors, nurses, is very low. One of the main reasons is a better opportunity for young doctors for career building. It results in the recruitment of new and often inexperienced staff and consequently a decline in the quality of the service.

"For example, many doctors appear for BCS (Bangladesh Civil Service) exam and will leave if selected. So a new batch will come, and if they find a better offer elsewhere, will leave too." Res 02_PI_LNGO

The frequent turnover is also typical among other staff, especially MIS officers. The loss of experienced and trained personnel at different levels contributes to poor quality of care and additional use of resources and funds for the capacity development of recruits. Despite the frequent turnover, vacant posts are filled up almost immediately. Internal recruitment was preferable to avoid the pressure from local political and influential leaders to recruit their candidates.

Capacity development of recruits.

The recruits require immediate training to boost their knowledge and skills. However, few respondents mentioned attending training not relevant to their works was another challenge. While organizing new training is common, refresher training or post-training supervision is usually rare. Attending Training also causes a problem such as the disruption of the service provision.

"Sometimes, there is a request for multiple training on the same day. And if the doctor leaves for training, then the facility is empty." Res 39_PI_UN

The necessity of particular cadre.

Many of the respondents (7) mentioned that the shortage of staff is not a problem unless staff goes for a holiday or there is a sudden surge of patients. However, rational distribution and availability of specialized staff are still missing.

"Why should I have ten health facilities when I do not have enough staff to run all of them? I would rather have few do it perfectly than to have so many………. Human resource is not rationally distributed. Some have more some have less. On the side of MNCH, I think most organizations do not have enough midwives." Res 41_PI_INGO

The health posts require more female doctors and midwives, as the conservative FDMN community preferred them as service providers. Additionally, three respondents mentioned appointing more field monitoring staff can improve the quality of service through tracking and monitoring.

Supply chain management.

The maintenance of medical supplies poses concern as all warehouses don't have qualified logistician and thus fail to maintain quality. Many of the medicines are temperature sensitive and need to be preserved in the storehouse with a functional cooling system or air-condition, which is missing in many stores. There is also a shortage of anesthetic agents for manual removal of the placenta and Vacuum extractor for normal delivery.

The injectable form of both painkillers and antibiotics for babies, including pediatric dropper for liquid medicine for neonates are also in shortage. Scarcities and delay in the refilling of iron and folic acid, vitamin, calcium tablets are noted.

"As most of the patients are children, the scarcity of pediatric medicines is common. We need them most. We try to manage as much as we can. But if the gap remains, we have nothing to do." Res 01_PI_LNGO

International procurement consumes more time.

Almost all international organizations procure their medical supplies from abroad due to their unavailability in the local market and to maintain a good standard. They do so by having long term agreements with their suppliers. However, this takes up too much time for the steps involved in the process. One respondent said,

"We have international procurement, which is very time-consuming. . . . It comes from abroad in a shipment, and we need a shipment clearance and stuff. We follow the normal procedures and systems, but clearing the shipment is difficult." Res 39_PI_UN

Health information system.

The challenges related to the health information system is not uncommon. All respondents mentioned that report to the common DHIS-2 platform set up by the Government is mandatory. According to one respondent, complexity arises because of too many indicators and frequent changes in the format of the report based on an individual's choice. Inconsistency of data uploaded on the website and over-reporting are other significant challenges with the health information system. The over-reporting is common due to the absence of a tracking system, lack of coordination among the different organization, and weak monitoring system.

"There are too many indicators, which should be reduced. Whenever someone comes, that thinks of adding something here, right here. Formats are randomly created whenever someone needs it." Res 24_PI_INGO

Several respondents mentioned the absence of an individual patient tracking system makes it hard to provide a continuum of care. The inaccuracy of the data due to the mistakes during medical diagnosis made by the data entry operator with no exposure to medical vocabulary has been reported frequently. Variety in the types of reporting and a large number of report submissions is quite challenging for the respondents. The differences among the organizational priorities often hinder data sharing opportunities. In the respondent’s voice,

"Different organizations have different reporting and requirements, and it is hard to fulfill all of them.” Res 39_PI_UN

Transportation channel for delivering supplies to the camps.

Providing supplies to the beneficiaries is problematic due to the lack of proper transportation channels. The poor network of roads, especially damaged roads, making it hard to transport supplies without damaging the supply. Some organizations rent vehicles for transporting supplies, which are time-consuming and incurs extra costs.

Also, there is a big challenge for transporting supplies to the warehouses located in the camps. FDMN community sometimes blocks the truck movement because they are afraid of the accident for themselves and for the children who use the road as a playground.

Shortage and cutting down in funding.

Implementing the MNCH program is becoming difficult not only because of the gradual shrinkage of the funding but also due to the pressure from the donor agencies to cut down the expenditure. Organizations can rarely employ international staff qualified for working in such an emergency setting because of the lack of funds. The human resources available in Bangladesh, especially for the higher-level positions, are not adequately qualified for working in a humanitarian crisis setting. Retaining highly qualified Bangladeshi personnel requires higher salaries. Moreover, funding is also needed to provide continuous training and capacity building for all the staff.

Security.

Another challenge against an enabling environment is a gradual increase in crime and violence. The extensive and comprehensive coordination and cooperation between the government, the army, and the implementing organizations have been launched to address the security concern.

"Bangladesh Army has played a great role. They ensure road connectivity of some strategic location and also traffic control within the camp, security management as well. Along with the Army, Bangladesh Police force also took the visible initiative, which facilitates the task of supply change management easier, and we will progress day by day." Res 23_PI_INGO

Besides that, UN agencies have policies and guidelines to ensure the security and wellbeing of humanitarian responders. Any unwanted incidence is managed according to the protocol. The ‘Majhi’ is a community leader in the FDMN population and appointed by the different organizations to act as community-level volunteers for the social mobilization activities, often helps other CHWs in their works by using their influence as the local community leaders.

"Block "Majhis" are prior informed [from the hospital], for solving any problem. However, while walking, some people comment on us, and Then "Majhi" tell the community look they are like us and respect them like your mother and sisters." Res 20_CO_LNGO

Increase coordination among organizations.

Three respondents mentioned that coordinated efforts between the government and other implementing organizations to reduce overlapping of service delivery are ongoing but not fully functional. Some overlaps are unavoidable, but through mapping of the working areas with allocating the activities can reduce further overlapping.

Another coordinated effort is task-shifting at the field level that reduced the high workload at the health facilities. Some health facilities are already using to tackle higher patient load.

Strengthening referral.

An effective referral system is critical for ensuring timely care. A standard solution to overcome the barriers to referral is to employ and train staff, especially the referral managers, and the creation of a rotational duty. Forming a partnership with the private facilities and better communication with the existing referral clinics in the camps is critical for an effective referral system.

"When the patient is in an emergency, we communicated with the private obstetrician. They treat or operate the patient. We reimburse the clinic afterward." Res 30_PI_INGO

Staff motivation.

Motivating the overburdened staff is another effective strategy. The provision of performance-based incentives, both in-kind and cash, has been introduced. Many organizations select the best performers and send them to specialized training or special events both within and outside Bangladesh. Other strategies include supportive supervision, delivering an inspiring speech in the meeting, and provision of health insurance.

"What we do is specific and unique training, and we cannot send all of them. We want to send someone who is committed, hardworking, collaborative, and energetic, that's whom we prioritize for those specific and important training… That's one way of motivation. Second, we promoted several staff for their performance." Res 40_PI_INGO

Capacity building.

The standard strategy adopted by the organizations to tackle the shortage of experienced staff is the provision of in-house training sessions with regular refresher training. The working teams provide each other support and guidance daily, sometimes even over the phone. The monthly or weekly staff meetings are a platform for discussing the gaps and the solution.

"Yes, those who are newcomers, they might not be knowledgeable about everything. They are continuously learning, and the older ones are helping them with it. We are giving them guidelines and guidance. Problems are also being solved almost immediately by arranging formal training and meetings." Res 23_PI_INGO

The organizations maintain staff capacity assessments using checklists and tools to identify training needs. They organize weekly continued medical education sessions and other knowledge-sharing sessions. In the morning sessions, doctors and supervisors discuss with the colleagues about ANC, PNC, breastfeeding, etc. Sometimes role-play of counseling sessions is conducted to practice how a counselor can convince a pregnant woman to visit the facility. Various external training was also organized by different agencies like UNICEF and others in collaboration with the government.

As there is a shortage of MIS staff, other staff are trained for the data reporting and related tasks and to use tablets instead of doing tally sheets on paper.

The logisticians received supply chain management training for ensuring quality control. One respondent said,

"When they detect they have a problem, they call on me, or they write me an email (saying things like) "I need support. Can you send me a team to come and help me organize my warehouse" I dispatch two people, (saying) "Go to location X, and fix that warehouse? Put it to the standard"" Res 27_PI_UN

Expiry dates are monitored using color-coding the stocks in a spreadsheet for identifying the shelf life of the medicines. The warning system allows the providers to consume the drugs before expiration. A guideline has been developed to dispose of expired medication.

“So we have a guideline on managing expired drugs. So I think, last year it has been developed, and it is also work in progress." Res 38_PI_INGO

Central coordination and long-term agreements for an effective supply chain.

Previously when the supply of medicines and other logistics were in dire need, the regular procurement process was made flexible by using a longstanding agreement with the supplier. Therefore, the procedure was easier and quicker, but it became slower. In this respect one respondent said,

"At the beginning of this emergency, receiving supplies required one week or 15 days if you have a long term agreement with the supplier. It took only three days..” Res 27_PI_UN

Validating local procurement sources.

Some implementers procured medicines and logistics in greater quantity and ordering it twice a year rather than three times a year. The gradual increase of validated, locally manufactured medications can reduce the burden of international procurement and save time. One respondent in this regard said,

“……..Bangladesh has many pharmaceutical companies. … …..while waiting for prequalification from WHO, each organization can also do the quality standard by in-house quality team. We already have data that are validated. The number of drugs for local purchase will continue sometime soon.” Res 41_PI_INGO